00:00:14: Ladies and gentlemen, boys and girls, welcome to the Staying Aligned podcast.

00:00:19: I am your host per usual, Alexander Eisner.

00:00:22: I am joined today, of course.

00:00:25: by the plucky-ever-present Sean Steele of Steele Eisner.

00:00:29: And today, the two of us are joined by a new, not only a new guest of the podcast, but a new specialty to the podcast.

00:00:39: And we are very happy to welcome Jerry Attrition and internist Dr.

00:00:43: Legrelli as doctor.

00:00:45: Thank you for being with us.

00:00:47: Thank you for asking me to join you.

00:00:51: I had a little bit of leverage on this.

00:00:53: Dr.

00:00:53: Tom is my personal concierge doctor.

00:00:58: That's a different animal altogether.

00:01:00: That means I can call him anytime except between two and three in the morning on a twenty-four hour basis.

00:01:07: If I got any issues, I can text him.

00:01:10: He texts me back.

00:01:12: And so we do.

00:01:13: So I don't have to go through the whole.

00:01:16: Gambit of going through assistance for assistance.

00:01:19: So it's direct personal kind of me on Saturday mornings.

00:01:23: It's it's.

00:01:23: it's nice to have but he's also specializes in old folks.

00:01:27: I barely qualify because I'm still a young man in search of a dream.

00:01:31: So he listens to my concerns and you know, he's a nice doctor and say I'm exaggerating.

00:01:37: but what we don't exaggerate is that Alex and I handle significant mid and high level trauma cases and Oftentimes we'll get an older folk, you know, seventy, eighty, ninety years old and bald and a serious collision, and they don't heal us fast.

00:01:52: And most people say, yeah, it's old age.

00:01:54: That's why, but there's spec, specificities in this old age that I want to talk to Dr.

00:02:00: Tom about.

00:02:00: And he deals with a lot of old folks that keep some healthy and spry and, and nice and active.

00:02:05: And, and frankly, he wouldn't be so busy if he wasn't so successful.

00:02:09: If his patient started moving on into the afterlife, he'd be.

00:02:14: Not busy at all.

00:02:15: and he's Sean

00:02:15: you're you're you're waving HIPAA right for purposes of this podcast.

00:02:19: We can ask him all about your your personal medical history,

00:02:22: right?

00:02:22: That's that's fine.

00:02:23: And I often wave HIPAA by because it gets in a way.

00:02:26: Ted Kennedy made great decisions when he passed that law thirty years ago.

00:02:31: Dr.

00:02:31: Legrelius, I want to ask you just to introduce yourself a little bit.

00:02:35: Tell tell everyone who's listening what what your specialties are and and what you're doing now in clinical practice.

00:02:41: Okay, um I'm a senior physician myself.

00:02:44: I'm actually eighty-two years old but don't have any plans to retire.

00:02:48: I've been in practice since actually private practice since nineteen seventy-four.

00:02:54: I'm a graduate of the University of Washington School of Medicine, did a residency at USC, got geriatric certified about thirty-fourty years ago, and run a three-doctor concierge practice in Torrance, California with two younger partners who are One's an internist geriatrician.

00:03:13: The other's a family practitioner geriatrician.

00:03:15: And the concierge practice consists of a little under a thousand patients, three or four hundred for each of us.

00:03:23: And as Sean said, we're available twenty four seven three sixty five to our patients.

00:03:30: We promise them same day or next day appointments.

00:03:32: We do detailed geriatric care.

00:03:34: We manage patients in the hospital.

00:03:37: I'm also the president of a national a country's physician's professional society called the American College of Private Physicians.

00:03:47: Now that's my background.

00:03:49: I don't plan to retire.

00:03:50: I enjoy what I do and I kind of practice what I preach in terms of longevity recommendations.

00:03:58: So I'm in pretty good shape.

00:04:01: I continue to fly airplanes and be pretty active.

00:04:06: So far, the brain still works.

00:04:08: My two young partners tell me that they don't want me to retire, but they'll let me know if I can't work anymore because I'm losing it.

00:04:16: I say the same thing to Sean all the time.

00:04:19: He says it way too often for his own good, frankly.

00:04:24: Let me just start by some disambiguation of terms.

00:04:28: So there's geriatrician and there's gerontologist or gerontology.

00:04:35: The gerontologist is not a physician.

00:04:37: A gerontologist is someone, usually a PhD with a master's degree, who studies aging and elderly people academically, but he's not a physician.

00:04:48: A geriatrician is first a physician, and he manages medical care on patients.

00:04:54: He may do other things too.

00:04:55: He may do research in gerontology, if you will, but geriatrician is a physician first and foremost, and most of them actually take care of patients.

00:05:04: Is there a board certification for geriatric, what would you call that?

00:05:09: There is a board certification in geriatric medicine, yes, and it's available to people who are board certified in family practice or internal medicine.

00:05:19: They can then do a fellowship in geriatrics and be board certified in that subspecialty.

00:05:24: It is a subspecialty.

00:05:26: Yeah,

00:05:27: so

00:05:28: Sean's right.

00:05:29: We do deal every day with people who've been in car accidents or other traumatic slip and fall, trip and fall situations.

00:05:36: Just like I

00:05:37: imagine... Airplane accidents?

00:05:38: Airplane

00:05:39: accidents.

00:05:39: Just like I imagine you do, Doug.

00:05:41: I imagine you're dealing, particularly with your patient base, you're dealing with a lot of trip and falls and slip and falls.

00:05:46: You're dealing with some car accidents.

00:05:50: But there is something inherently different and I don't think you need to be a specialist necessarily to spot the trend that older patients do tend to have, I mean, worse outcomes is certainly a broad based statement, but just a harder go of it in the recovery from traumatic accidents like car accidents and falls.

00:06:12: both from just the healing of the underlying like the trauma like if they broke their hip or their leg just the healing of that injury but also with all of these ancillary things that seem to happen to them during the recovery process.

00:06:24: that don't seem to happen as often and again this is anecdotal don't seem to happen to younger patients that have the same the same thing happen to them.

00:06:33: can you speak to that maybe from thirty thousand feet?

00:06:36: uh to to to give you a metaphor

00:06:38: because aging is a real phenomenon, and it begins shortly after you reach maturity.

00:06:46: There's a way of estimating aging called a methylation method, and if you use that method to evaluate people's actual age, it turns out that human beings are really designed to die when they're about forty or fifty, and after that we're just saving off death, I have to check something out.

00:07:10: We're just staving off death and deterioration.

00:07:14: And what medical science has done in the last hundred years or so is we've learned to treat the diseases of aging, which used to kill people very young.

00:07:25: As you all know, the life expectancy in the eighteen hundreds was in the forties or maybe fifties at best.

00:07:32: And now we've pushed it up to seventies or maybe eighties or so.

00:07:36: by treating diseases that people would have previously died of at a young age.

00:07:42: I mean, I've had at least two or three medical problems that probably would have killed me a couple of hundred years ago, but medical science saved me from those age-related diseases and I'm functional and healthy.

00:07:56: And that's what we have done in medical science.

00:07:58: What we have done is not address the issue of actual aging, so much as address the age-related diseases that take us out at a relatively young age if we don't get medical care, but we survive through to see the final results of aging.

00:08:16: And once you get through that, The rate of aging is variable from person to person.

00:08:23: I mean, I'm sure you've all met people who look and act and seem extremely old and they're sixty.

00:08:28: And you've also met people who are in their nineties and seem to be vigorous.

00:08:32: One of my patients is ninety-four and he comes in his pinstripe suit with his entourage and he runs an international construction company and he flies all over the world and builds buildings and he's perfectly healthy and acts like you or me.

00:08:49: And I also have patients who are sixty-five and can barely function and barely walk.

00:08:55: But the degenerative processes that occur and the weakening processes that occur with aging make it harder for people to heal once they're injured.

00:09:05: One thing that happens to many, many people as they age is they develop osteoporosis.

00:09:10: So relatively minor injuries and falls on the surface, not from high places, but just on the surface walking around.

00:09:18: can end up causing much more serious injuries, fractures that wouldn't have occurred if you were younger, subdural hematomas and bleeds into the brain from minor head injuries because they're traumatized.

00:09:31: A lot of seniors, because we are dealing with chronic illnesses that we can now address, are on a lot of medications.

00:09:41: And some of these medications can produce serious problems.

00:09:45: I've got a lot of patients on anti-quagulation for one reason or another.

00:09:49: They're on anti-quagulations because of their heart rhythms like atrial fibrillation or because they've had strokes and they need anti-quagulation or they've had coronary disease and they need anti-quagulation.

00:09:59: And therefore when they fall and injure themselves, they bleed easily.

00:10:04: And one of the problems that develops is Relatively minor injuries tend to be under-evaluated and under-diagnosed.

00:10:15: I saw a patient very recently who had no good history of injury, but he came in with a swollen wrist, and I knew that wrist was arthritic.

00:10:25: It had a lot of osteoarthritis in it, but I took an x-ray of it, and he had acute navicular fracture in that wrist.

00:10:31: I couldn't even get a history of a fall.

00:10:34: The patient was mildly demented.

00:10:37: He didn't remember a lot of stuff, and his caregivers couldn't remember a fall, but this particular patient had probably injured his wrist in a minor injury in fall and fractured the navicular in his wrist, which as you probably know, or maybe you know, is a very serious injury.

00:10:52: Navicular bones in the wrist don't have much blood supply, and they're very hard to get to heal.

00:10:58: Often takes weeks and weeks in a totally immobilizing cast to get them to heal.

00:11:03: And in this particular patient's case, since he got pretty much better on a mild split, I elected not to really treat him.

00:11:10: I don't think that bone will ever heal, and we're just gonna try to keep him comfortable.

00:11:14: So, and I appreciate all of that.

00:11:16: I think that there's a lot, so essentially what I'm hearing is it's very multifaceted.

00:11:19: There's a lot of different causes for why geriatric patients respond differently to trauma than younger patients.

00:11:28: But one thing that seems to happen, and I have a patient right now that this is, or a client rather, that's happening too, It's, you know, eighty-something year old woman was totally self-sufficient living with her husband, talking and walking and had a pretty significantly high quality of life, was involved in a fall, fell and I think she broke her hip in a parking lot, just, you know, didn't fall from any height.

00:11:55: And her condition deteriorated rapidly.

00:12:01: not just the hip injury.

00:12:02: I mean, the hip injury I think is actually mostly healed at this point, but she, I mean, she's non-verbal now.

00:12:09: She needs full-time care for all bodily functions and her all of activities at daily living are now being done by her husband or caretaker.

00:12:19: And like a lot of that stuff doesn't even seem to a lay person like they would even be related.

00:12:25: I mean, verbal, for example, we lost.

00:12:29: We lost the good doctor.

00:12:30: Hopefully rejoins us.

00:12:31: He pressed a button.

00:12:32: I saw him press the button on on that.

00:12:36: Give me some more details on that Alex.

00:12:38: I'm gonna keep the thread on that case.

00:12:41: Yeah, it parking lot accident.

00:12:44: She was she had a walker so she.

00:12:46: So she had to walk her, so she was slower in the beginning.

00:12:48: Was she driving herself?

00:12:50: Was she in some kind of a care facility?

00:12:52: No,

00:12:52: no.

00:12:52: She was living in an apartment with her husband.

00:12:54: Okay.

00:12:55: Well, she's been taken to a care facility at this point.

00:12:59: No, she's got either her husband or a live-in caretaker that's been taken care of her since the fall.

00:13:07: And it's just been a really sad situation.

00:13:10: We lost Dr.

00:13:11: Legrelli.

00:13:11: Let's get him on the phone.

00:13:12: There he is.

00:13:12: He's back.

00:13:13: He's back, everybody.

00:13:14: We're in good shape.

00:13:15: Hi, doctor.

00:13:16: Don't know what happened.

00:13:18: That's all right.

00:13:18: I saw you touching the computer so be careful

00:13:21: I may have docked it off.

00:13:23: So I think I think you more or less heard the end of my my story.

00:13:26: there I mean some of the stuff like like her verbal I mean her ability to speak and and just other general conditions of you know ability to take care of herself just completely plummeted down to zero after you know what I mean.

00:13:40: it was certainly a traumatic fall but You wouldn't think it would have all of these far-reaching ramifications.

00:13:48: That is just a fact.

00:13:50: In the geriatric population, a hip fracture predicts for either chronic disability where you're not going to be able to walk at all or death within a year or so.

00:14:07: Whereas if you're twenty or thirty and you happen to break your hip would be a required tremendous amount of trauma.

00:14:14: doesn't require a tremendous amount of trauma in an in an eighty-year-old but in a twenty-year-old it does.

00:14:19: you can predict that in a twenty or thirty or even forty-year-old a hip fracture is going to result in complete recovery in a few weeks.

00:14:26: we fix it and they're up running around doing their thing.

00:14:29: but in seniors who are who have gone through all the aging process have osteoporosis have multiple other underlying medical problems it predicts for at least half the patients having either a permanent disability and unable to walk independently in the future, land in a nursing home for the rest of their lives, or die.

00:14:54: And without really excellent supportive medical care, that becomes an even higher risk.

00:15:03: This might be an ignorant question born out of my own ignorance, but why would a hip fracture cause death?

00:15:12: or or or the inability to speak or to the inability to use her arms to take care of her.

00:15:18: So I mean, like she her condition plummeted and I don't think this is particularly rare.

00:15:22: I think this is pretty common.

00:15:23: Like you're saying, why is and why does that happen?

00:15:26: Well, I can't speak to the particular case you're you're talking about because I don't know the details of the case.

00:15:33: But all of these patients have advanced.

00:15:37: not not all but most of these patients have advanced multi system disease.

00:15:43: Most seniors have vascular disease.

00:15:46: They are at risk of strokes.

00:15:48: They often have carotid artery calcifications which can flake off and cause strokes.

00:15:54: They have relative osteoporosis compared with somebody much younger.

00:15:59: Their bones are weak.

00:16:00: They don't heal well.

00:16:01: They don't heal rapidly.

00:16:03: They have to go through a long process of rehabilitation because they're elderly and weak and debilitated.

00:16:12: And even if they look pretty good to you just before the injury, they can't do what they were able to do thirty years before.

00:16:19: I mean, even I, at age eighty-two, I still ride bicycles.

00:16:23: I can still walk pretty fast.

00:16:25: I don't run anymore.

00:16:28: I do have an artificial hip because I fractured it and had to have it replaced.

00:16:36: from running.

00:16:38: I ruined the dome of the bone by running on it too much.

00:16:43: It collapsed.

00:16:44: And I recovered from that.

00:16:47: I was age seventy-eight when that happened.

00:16:49: but I had super medical care and super motivation.

00:16:53: Many of these patients don't have super medical care.

00:16:55: They don't have super motivation.

00:16:57: It's incredibly important that the orthopedist or the chiropractor who was ever working with the patient's orthopedic injury coordinate with their medical care and that the patient, and to make sure the patient has optimal primary medical care and specialty medical care in the fields that don't involve their injury.

00:17:18: And a lot of people are not addressing those issues.

00:17:21: I think the first thing that a chiropractor or any trauma surgeon of any kind should do when dealing with such patients is get somebody like me involved in their care and see if we can optimize their other medical issues so that they don't end up with that terrible rapid slide, which we see so often.

00:17:46: Tom.

00:17:46: Where do you get the motivation?

00:17:48: That's a personal trait, isn't it?

00:17:50: I mean, you can't instill it or inject it in a patient.

00:17:53: So they have to have some desire themselves to want to get well as quickly as possible.

00:18:01: And that's another thing that happens in advanced age.

00:18:03: You're dealing with depression frequently.

00:18:06: People have lost their loved ones.

00:18:08: They're alone.

00:18:10: They've had great losses.

00:18:14: in their personal life for one reason or another.

00:18:17: The optimism for the future is not there.

00:18:19: They know that at age eighty or eighty-five, they're not going to be around in twenty years.

00:18:26: Whereas when you're thirty, you assume that you're going to live indefinitely.

00:18:30: And they kind of get a give up attitude.

00:18:34: And when the give up attitude occurs, it's very hard to motivate patients to do much.

00:18:39: So these people need to be treated for depression.

00:18:43: mood depression, antidepressant, psychotherapy, cognitive therapy, that all needs to be addressed too if you're going to try to get them well again.

00:18:55: physically and functionally well again.

00:18:56: Acute rehab programs, like for example, we have at Providence Hospital in San Pedro, we have an excellent acute rehab program where people stay for weeks for rehabilitation from injuries.

00:19:07: And most of these people are elderly.

00:19:10: It's unusual to have somebody need that when they're thirty-five or forty.

00:19:13: They bounce right back from their injuries.

00:19:16: So you mentioned chiropractors there for a second made me think is there is there anything that from your perspective as a geriatrician and in clinical practice That you would convey to chiropractors and that's the audience that we're talking to right now About the treatment of geriatric patients Specifically post trauma.

00:19:38: I mean, is there anything that you think?

00:19:40: because a lot of these a lot of chiropractors are the first-line doctors for I mean, for all of their patients, but some of whom are elderly who get into a car accident or a slip and fall accident and they go to their chiropractor.

00:19:54: And we're seeing the trend positive that more and more people are using chiropractors as primary care physicians, particularly in the aftermath of, you know, musculoskeletal trauma.

00:20:06: I mean, what do you think that?

00:20:07: is there something you wish that chiropractors knew or that you would convey to them from your position as a physician?

00:20:14: Well, I think the first thing they need to ask the patient is if they have a primary care doctor.

00:20:19: Many don't.

00:20:20: A lot of people don't have any resource for primary care.

00:20:24: Secondly, they need to coordinate with that doctor if they have one and get a history on the patient's medical situation.

00:20:32: One of the things I think chiropractors ought to do is realize that minor injuries can be much more serious than they appear to be on the surface.

00:20:41: A minor head bump can be a brain hemorrhage, and a lot of imaging should be done.

00:20:46: I think when you're seeing an elderly person with an injury, you ought to make sure they don't have osteoporosis.

00:20:51: I don't know if many chiropractors have them, but I think chiropractors should have some device in their office to check for osteoporosis.

00:21:00: What kind of device would you suggest, for example?

00:21:03: Well, the simplest one I would suggest is one of these heel ultrasound machines.

00:21:08: You've had your bone density checked in my office with that machine.

00:21:11: It's very simple.

00:21:12: It's very small.

00:21:13: It's inexpensive.

00:21:14: It can be operated by a medical assistant.

00:21:16: It doesn't involve x-ray.

00:21:18: And you just put your heel in it, and it'll measure your bone density quite accurately.

00:21:22: It has about a ninety percent correlation with dexa scanning of the hip and the spine.

00:21:28: And I think every chiropractor should know whether their elderly patient has osteoporosis or osteopenia because their fractures are going to be much more likely to occur, number one, and slower to heal.

00:21:40: There's a lot of things that need to be done for patients to help their bones heal faster.

00:21:46: Calcium supplements, vitamin D supplements, vitamin K-II supplements are very important in helping to build bone and incorporate calcium into building bone.

00:21:58: So a connection with the patient's medical team and an evaluation of their osteoporosis level and an evaluation of their cognitive level, I think patients who have injuries should be checked for cognition, whether or not they're even capable of following the directions you want them to follow.

00:22:19: Many patients will not remember what you've told them.

00:22:22: I think it's very important to write down what you want them to do, especially if their cognition is poor and detailed explanations.

00:22:31: For many seniors, you need a caregiver, a younger person who's going to surrogate for them and manage the care and make sure they do what you're recommending that they do.

00:22:43: So it's a multifactorial problem, coordinating with the primary care doctor, making sure that the patient who doesn't have a primary care doctor gets a medical evaluation from at least an internist or a family practitioner, but ideally from a geriatrician.

00:22:59: And the other problem is there are only six thousand geriatricians in the entire United States.

00:23:04: That's not very many when you consider how many seniors there are.

00:23:10: We can't possibly have a geriatrician for every senior patient in the country.

00:23:16: It's just not practical, but there are primary care doctors that can serve pretty well in that function.

00:23:25: I love what you said about communicating with the PCP.

00:23:30: I preach that a lot, that chiropractors should pick up that thousand-pound instrument on their desk and call the patient's primary care doctor.

00:23:40: and just have a conversation or ask to see their chart or just.

00:23:44: coordinate care, not just for geriatric patients, but it's especially important, like you said, because you don't have a good history.

00:23:52: And you can learn a lot from that coordination of care, and the result could be a much better outcome and more focused treatment plan for the patient.

00:24:04: I think that's phenomenal advice, actually.

00:24:07: Sean, what were you going to say?

00:24:08: There's so much going on here.

00:24:09: This has been a very fast half an hour.

00:24:12: Besides the cognition test, and I'm thinking seriously that maybe chiropractors should employ them.

00:24:18: Certainly the osteoarthritis test I think is really simple and straightforward and gives you so much information.

00:24:26: But the third level is maybe get the primary care of doctors records for the last year or two.

00:24:31: And that's easy.

00:24:32: We pull records constantly from the urgent care from the emergency room.

00:24:37: From the hospital.

00:24:38: but why not go after the primary care doctor see what's going on in that patient's life if they're elderly and they're suffering Really some very strange deterioration right after what seems to be kind of an average moderate type of accident And I think that could be useful.

00:24:53: We're I think modern chiropractors are trained much better in in in Traditional medical issues than they used to be And I think that's important that that chiropractors address these medical issues.

00:25:09: But if they're not comfortable with them, for sure they got to go to the MD or the DO.

00:25:14: that's managing the patient's regular medical care and get that information.

00:25:18: So we're down to the last four minutes here, and I would be remiss if I didn't ask the question that I like to ask every guest more or less, which is, what does the future look like?

00:25:29: You definitely, I think, nailed something that most people don't really think too much about, which is that We don't yet treat aging.

00:25:39: We just treat the diseases that affect older people.

00:25:43: in an effort to elongate people's lives.

00:25:45: Is there anything on the horizon that you think is promising that there's any hope for?

00:25:51: Yes, this has been my fascination all my life.

00:25:54: When I was a twenty-year-old pre-medical student, I used to spend my time in the medical library reading about aging.

00:25:59: It's not an accident that I'm a geriatrician.

00:26:01: There are lots of things going on.

00:26:04: We have a number of drugs that clearly extend life expectancy.

00:26:10: One proven drug that works well is metformin.

00:26:13: It's a diabetes drug and it's shown clearly to retard aging and improve longevity and health span.

00:26:23: There are an awful lot of supplements now that seem to have beneficial effects, quercetin and a long list of things.

00:26:30: There's a drug called rapamycin.

00:26:32: which was discovered in the sixties in Rapa Nui Island as a chemical in a streptomycin bacteria, which has dramatic life extension effects, but it has risks and dangers.

00:26:45: And there are people who are working with that drug and derivatives of it, which are even better.

00:26:51: There's a couple of experimental derivatives of it, which get rid of some of its adverse effects and seemingly only work on the beneficial side.

00:27:00: There's a long, long, long literature now on anti-aging.

00:27:04: And I expect that people who are born now, many of them are going to live way into their hundred and fifty, hundred and thirty age because we are going to stop aging.

00:27:14: There isn't any reason we have to age.

00:27:17: It's a biochemically program process in cells.

00:27:20: It can be stopped.

00:27:21: It can be slowed down.

00:27:23: There are an awful lot of animals that live to be two or three hundred years old and only die because a predator got them or a disease got them.

00:27:29: Tortoises, for example.

00:27:31: There's a tortoise that's two hundred and fifty years old right now.

00:27:34: And if it wasn't for diseases and trauma and predators, some animals would never die.

00:27:41: Why do we age?

00:27:42: That's a very complicated question and one I have a great fascination with.

00:27:46: We should do a whole program on that.

00:27:49: We are.

00:27:50: This has been one of the better half an hour.

00:27:52: I

00:27:52: couldn't agree more.

00:27:55: I'm taken by the last four minutes.

00:27:57: I want to do more research.

00:27:58: I want to learn about the future of this.

00:28:01: Sounds fascinating.

00:28:04: I've written an eight thousand word essay on anti-aging.

00:28:08: if you'd like to read it sometime.

00:28:09: You know what?

00:28:10: If you could email it to me, doctors, and this is public, of course.

00:28:16: Your article is publicly available.

00:28:18: Actually, it's not.

00:28:21: I give it to patients.

00:28:22: Well, okay.

00:28:23: Then apparently I got his permission to send it to everybody in the Western and Eastern world.

00:28:28: So send me a copy of that.

00:28:30: And if you're really fascinated and motivated, write me a note to my email and then give me three good reasons why you should have it.

00:28:38: How's that, doctor?

00:28:39: Is that?

00:28:39: Well,

00:28:39: I'm working on improving it every day.

00:28:42: It's quite not quite ready for prime time, except for limited publication.

00:28:48: Okay, send it to me.

00:28:49: I didn't

00:28:50: give a talk on it in Atlanta last two weeks ago.

00:28:53: I was invited to the concierge doctor's meeting and gave a half an hour talk on it.

00:28:58: Okay, I want the essay though.

00:29:00: And if you want me to have no circulation, that's fine.

00:29:04: I won't even give it to Alex.

00:29:05: Why should he have it anyhow?

00:29:07: Now, it's also true.

00:29:07: You don't need to worry about it, right?

00:29:09: Yeah,

00:29:10: not yet.

00:29:10: That's the point at which people should start worrying about it at Alan's age.

00:29:15: Should start worrying about what?

00:29:17: Aging

00:29:17: aging.

00:29:18: Yeah, you're well.

00:29:19: I'm not worried.

00:29:20: No, he thinks I should be worried.

00:29:23: Oh, yeah, well appropriate time to start treating Aging is right around the time when you know, it starts.

00:29:28: doc I can't thank you enough for being here I do want to make a brief pitch.

00:29:32: This is gonna go out.

00:29:34: the podcast is gonna be published the next day or two and next weekend not not this coming Halloween or the day after but the November eighth.

00:29:43: we have our advanced seminar.

00:29:46: This year, we're talking about the future of trauma, which is contrasted a little bit with the future of aging or anti-aging.

00:29:55: But great speaker lineup, Sean and I will be there.

00:29:58: Dr.

00:29:59: Collins, Sam Collins will be there.

00:30:02: Anonymous adjuster, we've got a defense attorney coming to give the defense perspective.

00:30:07: Orthopedic surgeon, a DAC bar, gonna come talk about that.

00:30:10: So really a great, great... it's going to be at the Anaheim Hotel, eight hours of continuing education.

00:30:18: If you're interested at all, there are some tickets left, but we are approaching standing room only at the last time I looked.

00:30:25: It's actually the best pre-sales we've ever had.

00:30:29: And so it's, you know, I don't think it has anything to do with Disneyland being across the street, but that does help.

00:30:37: It is a draw.

00:30:38: That's right.

00:30:38: So steelisner.com slash events.

00:30:41: you can go and get your tickets there.

00:30:45: and If there's still if there's still some left, I think there are.

00:30:49: so go check that out.

00:30:50: and Dr.

00:30:51: Lagrilius, are you?

00:30:52: I don't know if you're accepting patients or if anybody has a question for you and would want to get in touch with you.

00:30:57: Do you want to a plug?

00:30:59: Do you want to?

00:31:01: Well, you can go to the website skyparkpfc.com Or just call me, I mean, if you Google my name, you'll find all that stuff.

00:31:10: Lagrilius is only one of me.

00:31:14: Lagrilius is a rare name.

00:31:16: Good.

00:31:17: Great.

00:31:17: I just want to give you an opportunity for a nice plug.

00:31:19: I think you've certainly done us a service by coming on and I think all the time.

00:31:23: I'm not accepting any new patients, Alex.

00:31:25: I mean, the guy's busy spending half of his time flying to Mexico and Alaska and Lake Tahoe and other places in between.

00:31:33: So, but nonetheless, I

00:31:35: actually do accept that occasional new patients, although most of the new ones go to my two younger partners.

00:31:41: Yeah.

00:31:41: Yeah.

00:31:42: And he also teaches interns from USC.

00:31:45: So.

00:31:46: We appreciate that and we hope they teach Nebraska some lessons.

00:31:49: I

00:31:50: am an associate assistant professor at USC.

00:31:53: That's

00:31:54: true.

00:31:54: That's the lowest rank you can get and still be a professor.

00:31:58: Well,

00:31:58: Alex is even lower than that, but he's a sometimes lecturer at Loyola Law School.

00:32:04: What's your exact title?

00:32:05: Don't tell me it's adjunct professor adjunct

00:32:08: professor.

00:32:08: Yeah,

00:32:08: it's actually.

00:32:09: I'm an associate assistant adjunct.

00:32:11: Yes

00:32:13: It's the assistant of the associate assistant

00:32:17: and you can't get a little over than that.

00:32:19: No,

00:32:19: I don't think so.

00:32:20: That's

00:32:20: two two two professors and and and me.

00:32:23: That's good

00:32:24: Too professor.

00:32:25: Well, were you named the podcast?

00:32:26: two professors and Sean the dr.

00:32:28: Oleg really is.

00:32:29: thank you so much for being here.

00:32:30: We really really appreciate it And and we'll catch you on the next one.

00:32:35: Thank you.

00:32:35: Bye

00:32:36: bye.